UK-APPLICATION FORM for Fellowship of Interventional Pain Practice

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6. E-mail___________________________________________________________________ 7. Date of birth ______________________________________________________________ Day month year 8. Gender _____ Female _____ Male (For statistical purposes only) Education List in chronological order all completed undergraduate, medical school and approved specialty training. Medical School Name of Institution Degree Dates FRCA or equivalent postgraduate diploma(s) Pain Fellowship N/A Full GMC Registration N/A Total number of years in practice after registration If you have successfully completed a pain fellowship training program in pain management that lasted 12 months or longer, you may count the fellowship training as equivalent to l year (maximum) of practice in Pain Management. 2
Your professional practice setting is: (tick all that apply.) _____ Medical School _____Private Practice, solo _____Private Practice, Group _____ Hospital Based _____ Outpatient Based _____ Military What percentage of your clinical practice is in the field of Pain Management ________________% List all posts held in Pain Management since registration in reverse chronological order starting with your current position. Dates Name of Your Institution/Practice Your Title/Position 3
Page 1: Section of Pain Practice UK-APPLICA
Page 5 and 6: Recommendations Indicate in the spa
Page 7 and 8: I understand that I must keep my li
Page 9 and 10: REQUIREMENT OF Ethical And Professi
Page 11 and 12: All exam fees must be paid in $US a

UK-APPLICATION FORM for Fellowship of Interventional Pain Practice

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